Disabilities: Back pain due to symptoms of lumbosacral radiculopathy; cervical, thoracic, and lumbar disc disease, tethered spinal cord, diastematomyelia, and release of tethered spinal cord. A treating neurologist advised Hartford that Campbell had back and spinal operations in 2008, 2009, and 2011, that she could not work without restrictions and that she could not return to work with restrictions.

Definition of Disability in the Plan/Policy: "Disability or Disabled means You are prevented from performing one or more of the Essential Duties of: 1) Your Occupation during the Elimination Period; 2) Your Occupation for the 24 month(s) following the Elimination Period . . .; and 3) after that, Any Occupation.

Other important factors: There was video surveillance conducted by an investigave firm at Hartford’s request. [Note: we have found that Hartford is one of the most likely disability insurance companies to conduct video surveillance.]. Campbell was filmed driving, running errands, and going to the gym.

Key Physician Opinions: On January 28, 2016, Hartford sent the surveillance video, the surveillance investigator’s report, and the interview transcript to treating neurologist Dr. Bailyn, with a letter requesting that he consider those materials in conjunction with his medical findings and advise Hartford whether Campbell was capable of full-time work. Specifically, Hartford asked Dr. Bailyn to check “Yes” or “No” in response to the following: Specifically, we are asking your medical opinion as to whether Ms. Campbell currently has the functionality to perform activity as follows: 40 hours per week, primarily seated in nature, with occasional walking and standing and[] allows for full use of the upper extremities. Lifting/carrying will be limited to 0-10 pounds on an occasional basis. Afforded will be the opportunity to change positions/postures as needed for comfort (by walking, standing, or moving about). On February 1, 2016, Dr. Bailyn checked “Yes,” signed the letter and returned it to Hartford. He also indicated that Campbell did not have any cognitive restrictions or limitations.

On appeal, Campbell submitted a Comprehensive Rehabilitation Evaluation and Medical Functional Capacity Assessment by Craig Lichtblau, M.D., board certified in Physical Medicine & Rehabilitation. Dr. Lichtblau listed and considered the extensive diagnostic and surgical procedures Campbell has undergone since 2007. Dr. Lichtblau concluded that Campbell “does not have the functional capacity to work 4 hours per day on an uninterrupted basis at this time.” Stating that Campbell “is going to suffer from acute, intermittent exacerbations of chronic pain and discomfort,” Dr. Lichtblau further opined that it was his medical opinion as a Board Certified Physiatrist that Campbell would be unable to maintain gainful employment in the competitive open labor market or in a sheltered work environment with a benevolent employer secondary to acute, intermittent exacerbations of chronic pain. [The Court noted, “Dr. Lichtblau did not, however, have the benefit of Hartford’s surveillance video.”]

Consultative Physician Opinions: Dr. Jares opined that as of the date Campbell ceased work “to the present date and beyond, the claimant may perform as follows: She may sit no more than 30 minutes at one time and no more than 2 hours total in an 8-hour work shift. She may stand no more than 10 minutes at a time and no more than 1 hour total in an 8-hour work shift. She may walk no more than 10 minutes at a time and no more than 1 hour total in an 8-hour work shift. . .”

To assist Hartford’s evaluation of the appeal, an “independent” peer review was conducted by Sarah White, M.D., also board certified in Physical Medicine and Rehabilitation. Dr. White reviewed the surveillance video as well as all available medical records. It is worth noting that Dr. White's review did not involve a physical personal evaluation of Campbell. Dr. White disagreed with Dr. Lichtblau's opinions regarding Campbell's limited function and work status as noted in his report of July 18, 2016. She opined, “[t]he findings on the video surveillance are inconsistent with an inability to perform all activities/work.”

The claimant’s response to video surveillance: Campbell's appeal letter noted that she told Hartford’s field investigator that she was encouraged by her previous physician to exercise to attempt to alleviate her pain by strengthening her core and that she had met with a personal trainer and been instructed how to use the machines. They had worked out a safe routine, which eventually she was able to do on her own. She felt safe, because she could always hang on to something while she used the machines. She had increased the frequency of her workouts but not extended their duration. She sensed some improvement in strength but no significant improvement in her pain.

Benefits Ever Paid? Yes. Based on Dr. Jares’ report that indicated Campbell was not even capable of full time sedentary work. However, benefits were later terminated.

Basis For Denial / Termination of Benefits: In correspondence dated February 17, 2016, Hartford advised Campbell that her LTD benefits were terminated effective February 17, 2016, based principally on the surveillance and Dr. Bailyn’s statement that she was capable of full time sedentary work.

Standard of Review: Arbitrary and capricious: “Here, the parties agree that the Policy unambiguously grants Hartford discretionary authority to construe its terms and determine eligibility for benefits thereunder. Thus, the Court will begin the analysis at step three of the Eleventh Circuit’s framework because “even assuming that [Defendant’s] decision was ‘de novo wrong’ ... the dispositive question is whether [Defendant’s] decision was arbitrary and capricious.””

Issues: Campbell asserted that she cannot perform a sedentary job because of disabling pain while sitting.

Holdings: “Based on the administrative record in this case, the Court concludes that the plan administrator possessed a reasonable basis for its benefit decision and that Hartford’s conflict of interest did not render that decision arbitrary and capricious.”

The court found that Hartford was within its right to conduct video surveillance, to have the surveillance footage reviewed by a consulting physician, and to rely on the consulting physician’s assessment of the claimant’s work capacity based on the surveillance and the claimant’s medical records.

The Court further held that Campbell’s own treating neurologist’s opinion “lends strong additional support to Hartford’s decision”:

“Under well-settled ERISA law,” a claim administrator’s reliance on a medical peer review is “entirely appropriate even where the reviewing consultant’s report rebuts the opinion of the treating physicians asserting claimant is disabled.” Ness v. Aetna Life Ins. Co., 257 F. Supp.3d 1280, 1291 (M.D. Fla. 2017) (citation omitted). Thus, Hartford’s reliance on Dr. White’s report is not improper even if one or more of Campbell’s treating physicians had disagreed. However, Campbell’s own treating neurologist, Dr. Bailyn, changed his opinion after reviewing the surveillance video, and checked a box indicating his opinion now was that Campbell was capable of full-time sedentary work."

In response to Campbell’s allegations that her pain render her disabled, the Court states, “However, an ERISA disability is not established “merely by the existence of pain, even chronic pain, in the absence of proof that the claimant’s pain actually precludes him or her from working.” Richey v. Hartford Life and Acc. Ins. Co., 608 F. Supp.2d 1306, 1310 (M.D. Fla. 2009) (“Richey”). Campbell therefore cannot meet her burden merely by pointing to her diagnoses and complaints of pain; rather, she must demonstrate that her symptoms precluded her from working in her own occupation.

If there is a reasonable basis, the decision “must be upheld as not being arbitrary or capricious, even if there is evidence that would support a contrary decision,” White v. The Coca–Cola Co., 542 F.3d 848, 856 (11th Cir. 2008), cert. denied, 556 U.S. 1166 (2009) (internal citation and quotation omitted), or “[if] the court or anyone else might reach a different conclusion.” Turner v. Delta Family–Care Disability and Survivorship Plan, 291 F.3d 1270, 1274 (11th Cir. 2002).

The administrator's decision “need not be the best possible decision, only one with a rational justification.” Griffis v. Delta Family-Care Disability, 723 F.2d 822, 825 (11th Cir. 1984).

Similarly, if the “evidence is close,” the administrator did not abuse its discretion, and the requisite deference compels the affirmance of the administrator’s decision. Doyle, 542 F.3d at 1363.

Summary: "Campbell’s ability to perform full-time sedentary work was confirmed by her own treating neurologist, and a board certified peer reviewer subsequently concurred. Hartford reasonably relied on those medical opinions and the surveillance evidence in deeming her ineligible for continued benefits. Hartford’s decision to terminate LTD benefits was rationally justified and thus is not arbitrary and capricious, entitling Hartford to summary judgment."

Disclaimer: This was not a case handled by the disability attorneys at the Ortiz Law Firm. The court case is summarized here to give readers a better understanding of how Federal Courts decide long term disability ERISA claims.

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